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Mastectomy for tumor

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IntroductionEdit

Mastectomy is the definitive treatment for breast cancer or DCIS. Before approaching the specimen, gather some information about the case:

  • What was the clinical problem?
    • Skin and nipple abnormality
    • Mass
    • Calcifications
    • MRI enhancement
  • What happened before mastectomy?
    • FNA or core biopsy only
      • Significance: a clip may be present.
    • Excisional biopsy (partial mastectomy)
      • Significance: a biopsy cavity may be present.
    • Excision with margin issues
      • Significance: a biopsy cavity may be present.
    • Neoadjuvant chemotherapy
      • Significance: there may be treatment effect.
  • Where was the cancer?
    • Radiology reports will tell you the location and number of lesions.


A simple mastectomy specimen consists of the breast only. A modified radical mastectomy includes the axillary tail, and you must examine the tail specifically for nodes.

Fresh HandlingEdit

  • Consult radiology reports and clinical history to determine the clinical scenario and guide your gross inspection.
  • Measure the breast, skin ellipse, nipple-areola complex and nipple.
  • Orient the breast using the surgeon’s sutures.
  • Ink the breast:
    • Anterosuperior: blue
    • Anteroinferior: green
    • Deep: black
  • Note that margins are seldom an issue in these specimens. The color is mostly for orientation.
  • Place the breast face-down on the table, oriented.
  • Section into quadrants using a Tissue-Tek knife, then section further in a pinwheel fashion.
  • Find the lesion or area of interest and document its characteristics:
    • If tumor:
      • Measurements in three dimensions.
      • Clock-face position (e.g., 9 o’clock) and/or quadrant.
      • Distance from nipple.
      • Distance from closest margin.
      • Appearance of cut surface.
    • If biopsy cavity:
      • Dimensions
      • Clock-face position
      • Distance from nipple
      • Appearance of cavity wall (hemorrhagic, fibrotic)
  • If tumor is present and large, take tumor and normal for tissue banking.
  • Fix specimen in a large quantity of formalin.



Grossing InEdit

If the specimen was thoroughly described in the fresh state, then most of the work is already done.

  • Submit sections:
    • Biopsy cavity in toto or representative if large.
    • Focus on area that prompted the mastectomy (e.g., anterior of cavity, if the anterior margin was positive on the biopsy)
    • Tumor in toto or up to 4 blocks.
    • 1-2 sections of black-inked margin deep to area of interest
    • 2 representative sections of each quadrant (UI, UO, LI, LO)
    • 1 section of nipple
    • Other suspicious foci
    • All intramammary lymph nodes
  • Examine the axillary tail:
    • Amputate the tail
    • Section through to find lymph nodes. There may be areas of scarring if there has been a prior sentinel node biopsy.
    • Submit all nodes. If large nodes are bisected, document this in your dictation. Include scarred areas since they may or may not include tumor.

Submit the case in a bucket designated for “breast”, “fat”, or “16 hour” processing (all of these mean the same thing).

Sample DictationEdit

Specimen #___ is received fresh, labeled with the patient’s name and medical record number, designated “______--“

And consists of an oriented/unoriented “Modified Radical Mastectomy/ Simple Mastectomy/ Simple skin sparing mastectomy” specimen, measuring ___ x ___ x ___ cm, with an overlying ellipse of skin measuring ___ x ___- x ___ cm, with the nipple-areola complex measuring ___ x ___ x ___ cm and the nipple measuring ___ x ___ x ___ cm. The skin and the nipple appear grossly unremarkable. No subareolar mass is palpated. / OR The skin shows an ill-defined, ulcerated, red-tan lesion measuring – x ___ x ___ cm. The nipple is everted /retracted, showing ulceration. The specimen is received oriented with a suture indicating the axillary tail and is inked as follows: Anterior-superior margin: Blue; Anterior-Inferior margin: Green; and Deep/Posterior margin: Black. The specimen is serially sectioned to reveal (predominantly adipose tissue with) approximately ___ % of fibroglandular stroma (OR the breast tissue is approximately ___ % stroma).

An ill-defined, firm, fibrotic area, probably representing the prior biopsy site, is identified, measuring ___ x ___ x ___ cm, located in the UOQ, LOQ, LIQ, UIQ, situated ___ cm from the lesion/mass and ___ cm from the closest ___ margin (margins)/ OR situated ___ cm from the anterior-superior, ___ cm from the anterior-inferior and ___ cm from the deep-posterior margins/ OR abutting the ___- margin. A clip is/ is not identified in this prior biopsy site.

OR

A solitary/___, ovoid/round/irregular (spiculated), solid/cystic, well/poorly circumscribed, nodular mass, measuring ___ x ___ x ___ cm, ___- in color, firm/soft/hard/schirrous in consistency, well/poorly encapsulated, with a homogenous/heterogeneous cut surface, with/without areas of hemorrhage and necrosis, located in the UOQ, LOQ, LIQ, UIQ, situated ___ cm from the closest ___ margin (margins)/ OR situated ___ cm from the anterior-superior, ___ cm from the anterior-inferior and ___ cm from the deep-posterior margins/ OR abutting the ___ margin, is identified. (An ill-defined, firm, fibrotic area, probably representing the prior biopsy site, is identified, measuring ___ x ___ x ___ cm, located in the UOQ, LOQ, LIQ, UIQ, situated ___ cm from the lesion/mass and ___ cm from the closest ___ margin (margins)/ OR situated ___ cm from the anterior-superior, ___ cm from the anterior-inferior and ___ cm from deep-posterior margins./ OR abutting the ___ margin. A clip is/ is not identified in this prior biopsy site).


Review and SignoutEdit

1. Left breast and axillary tail, mastectomy:

A. Invasive ductal carcinoma, ___ cm, (high, intermediate, low) grade, (resection margins free of involvement) or (___ cm from the superior/inferior/etc. resection margin), smd (F9).
B. Associated ductal carcinoma in situ, solid and/or cribiform pattern(s) (with comedo-type necrosis), (resection margins free of involvement) or (___ cm from the superior/inferior/etc. resection margin).
C. Skin and nipple, no carcinoma identified.
D. ___ axillary lymph nodes, no carcinoma identified (0/___) or Metastatic adenocarcinoma in ___/___ axillary lymph nodes (___/___).
A. Breast with biopsy site changes (or biopsy cavity), no residual carcinoma identified.
B. ___ lymph nodes, no carcinoma identified (0/___).



Return to Breast Grossing

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